Patient Care Advocate

Committed to the constant pursuit of excellence in improving the health status of the patient and decreasing hospital readmission rates, ensures the safe and effective transfers of patients across the care continuum, serving as the bridge between the professional staff in a care setting, (e.g. hospital), the patient and/or family and the community healthcare provider. Informs and guides both staff and patients working to ensure an effective care transition from the hospital to the patient’s home;

helps teach and train patient self-management skills as well as enhancing patient-healthcare provider communication; and provides support to ACTIVATE staff, Hospital personnel and community partners in the field, and provides assistance by phone or in-person to high-risk beneficiaries by identifying social determinants of health and connecting them to community services.

This position does not have direct reports.

% of Time

20%

• Runs and screens daily census reports for potential patient enrollments
• Meet with patient/family at hospital bedside to introduce the program and gather enrollment data
• Reinforces program enrollment and patient responsibilities with the patient and caregiver
• Prioritizes referrals and activities according to intensity, need, and required follow-up working to ensure outcomes are met.

45%

Ensuring professional boundaries are maintained with all aspects of patient’s interaction and care delivers patient care advocacy to include:

• Serves as a Patient Care Advocate to the patient, coaching the patient and caregivers in addressing social determinants of health
• Provides information and navigation to the patient and/or family for an effective care transition, improved patient self-management skills and enhanced patient-healthcare provider communication
• Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in:
• medication self-management
• use of a dynamic patient-centered record
• appropriate primary care and specialist follow-up
• knowledge of red flags
• Serves as a liaison between primary care providers, and community resources on behalf of patients to ensure patient-centered coordination of care
• Works in the hospital and community, makes rounds in the hospital, makes home visits and follow-up phone calls
• Acts as a continuing resource for the hospital personnel, patients and/or caregivers

20%

• Completes the necessary assessments and referrals by collecting data on clinical indicators
• Maintains databases on ACTIVATE-enrolled population ensuring accurate and timely documentation

20%

• Ensures compliance with all All Thrive 365 policies, procedures, and practices regarding the Activate Transitional Care program, and other contract and licensure requirements laws related to patient confidentiality, release of information, and HIPAA; and applies knowledge to the work in accordance with quality standards
• Uses safe work practices
• Promptly reports workplace and patient safety issues to supervisor
• Attends and actively participates in initial and on-going training and development programs and opportunities, weekly unit meetings all staff meetings, and demonstrates learned concepts on the job
• Participates in assigned work teams, as requested and appropriate
• Engages in continuous improvement efforts, as assigned, and strives to continuously improve the quality of care and self
• Communicates daily and as necessary with colleagues, supervisor, leadership and medical staff

5%

• Building, cleaning, and organizing durable medical equipment
• Other duties as assigned

• Bachelor’s Degree in Social Work, Human Services, Psychology or Public Health or Nurse (LPN or RN) Licensed by the Arizona Board of Nursing
• Minimum of 2 years of working with patients in a primary care setting or related work experience
• Valid AZ driver’s license and acceptable MVR
• Valid CPR/First Aid Certification or ability to obtain within 30 days of position entry
• Must be at least 21 years of age
• Clear fingerprint background screening through the Department of Public Safety and comprehensive…